Download Center for Educational and Psychological Services

Dean Hope Center
For Educational & Psychological Services
Teachers College, Columbia University
Box 91, 525 West 120th. Street, New York, N.Y. 10027-6696
Tel. (212) 678-3262 Fax. (212) 678-8105
Dinelia Rosa, Ph. D., Director
Adult Termination Summary
Client: _________________
Sex: _____
Date of Birth: __________________
Age: _______
Duration of Services:
Date completed: _____________
Date of last session: __________
Student: __________________
________________________________
The TERMINATION SUMMARY is the one report most likely to be read by someone in the future, as it is
the one usually sent out when the CEPS gets a request for old records. Think of the person who may be
working with your client in the future as your audience and review the entire course of your work with the
client.
Reason for referral: As per described in the Intake.
Description of client:
Describe the self-presentation of client during intake and at present. Describe any significant changes.
Chief complaint:
Describe briefly the original complaint in client’s own words and its change throughout the course of treatment
to the present.
Client history:
Knowing now all that you have learned about the client, summarize the most relevant factors, facts and events
in the client’s developmental, family, medical, social, educational and work history. If you are going to
describe changes, you must summarize the original situation described during intake to help the reader that
may not have the intake to review.
Presenting problems and stressors
Current environment
Alcohol and substance abuse
Developmental and social history
Gestation, infancy, childhood, and adolescence
Psychosexual history
Educational/Vocational history
Social history
Criminal/Legal history
Family history
Family composition and significant history
Family psychiatric and medical history
Medical history
Multicultural evaluation
Language
Migration history, if applicable:
Cultural and racial identity
Spiritual/Religious history
Acculturation
Summary of clinical impression and course of treatment:
Briefly summarize objective aspects of the service provision over the entire course of the treatment covering
matters such as frequency of sessions, client’s response to treatment structure (e.g. fees, appointments), and
summarizing material found in the service delivery section of earlier reports. Briefly review the issues and
problems that were of main concern at each phase of the treatment process, restate material in the service plan,
and focus sections of earlier reports
Provide final cultural formulation (Please refer to the DSM-V). If client provided a cultural explanation of
his/her presenting problem, indicate if there were any changes in that understanding. If client did not provide a
cultural explanation at the beginning, but did later on, describe any changes. Were there any changes in the
predominant idioms of distress through which symptoms or the need for social support were communicated,
the meaning and perceived severity of the symptoms in relation to norms of the cultural reference group?
Provide final Clinical formulation and impressions. Summarize your understanding of the nature, causes and
psychodynamics of the client’s problem; state your assessment of the client’s motivation and expectations for
treatment; describe the client’s strengths and weaknesses; integrate your own insights and relevant data from
the preceding sections in this section. Describe progress and changes in all of the above. Include all major
diagnostic and treatment considerations that were part of the work with the client. Include any changes in
defensive style and coping mechanisms. Provide supportive reasoning behind the diagnosis. Conclude with a
discussion of the termination. Why is the case being terminated at this time? What are the client’s feelings
about termination?
Mental Status Examination: Provide MSE at the time of termination.
Appearance and behavior
Speech
Mood and affect
Thought process
Thought content
Sensorium and cognitive functioning examination:
Memory
Judgment
Insight
Diagnosis:
Whether or not the diagnosis has changed, enter a full, DSM-V diagnosis here, using the format described in
the Intake Report sample.
Original DSM-V Diagnosis:
DSM-V moved to a non-axial format. Make full DSM-V diagnosis, using format shown. Do not use “No
Other Specified,” (NOS). Instead use “Other Specified,” or “Unspecified.”
Main Diagnosis:
_____.____ _____________________________________
Secondary Diagnosis (If applicable):_____.____ ___________________________
Personality Disorder: (If applicable): _____.____ ___________________________
In a separate paragraph and in a narrative way describe the psychosocial and environmental problems that
might be contributing to the diagnoses described above (Old Axis IV).
Final DSM-V Diagnosis:
DSM-V moved to a non-axial format. Make full DSM-V diagnosis, using format shown. Do not use “No
Other Specified,” (NOS). Instead use “Other Specified,” or “Unspecified.”
Main Diagnosis:
_____.____ _____________________________________
Secondary Diagnosis (If applicable):_____.____ ___________________________
Personality Disorder: (If applicable): _____.____ ___________________________
In a separate paragraph and in a narrative way describe the psychosocial and environmental problems that
might be contributing to the diagnoses described above (Old Axis IV).
Final Recommendations and Disposition:
Your last words as you look ahead! What is the client’s prognosis? What work remains to be done? Include
clinical and multicultural aspects. What is left to say about the client? What was discussed with the client in
terms of future recommendations and disposition? How did client feels about disposition plan? What might be
helpful to a future professional who someday may be reading your report?
Please indicate:
Continue in CEPS with _____ Doc. Student ____ Masters Student
Refer to CEPS for other services: _________________________________________________
Refer out of CEPS _____________________________________________________________
Trainee’s name: ___________________
Supervisor’s name: _________________________
Trainee’s signature: _________________
Supervisor’s signature: _____________________
Date: ____________
Date: ______________________